1. A. After a hospital's application for designation has been accepted, MIEMSS shall conduct an on-site review of a hospital that has applied to be a Primary Adult Resource Center, or a Level I, II, or III trauma center.

2. B. On-Site Review Teams.

   1. (1) MIEMSS shall establish multidisciplinary on-site review teams composed of individuals knowledgeable in trauma or specialty care and trauma or specialty care systems.
   2. (2) The composition of the team shall be appropriate to the level of designation sought.

   3. (3) For trauma center designation, MIEMSS shall select a team which, at a minimum, shall include MIEMSS staff and representatives from three of the following categories:

      1. (a) Trauma surgeon;
      2. (b) Emergency physician;
      3. (c) Trauma nurse coordinator;
      4. (d) Administrator.
   4. (4) A staff person from MIEMSS shall accompany and coordinate the functions of the review team.
   5. (5) A team shall consist of professionals who do not have any conflict or competitive interest with the applicant.
   6. (6) If a hospital can demonstrate a reasonable basis for concern, MIEMSS shall consider allegations that conflicts of interest exist between an on-site reviewer and an applicant.

   7. (7) Contact with Members of On-Site Review Team.

      1. (a) Except as authorized by MIEMSS, an applicant's administration, faculty, medical staff, employees, and representatives may not have any contact with an on-site review team member relating to the review process after the team members are announced and before the on-site review is conducted.
      2. (b) A violation of §B(7)(a) of this regulation may be grounds for denial by MIEMSS of the hospital's application.

   8. (8) The on-site review team shall:

      1. (a) Evaluate the appropriateness and capability of the applicant to provide trauma care services, according to the designation standards described in COMAR 30.08.05;

      2. (b) Verify the hospital's ability to meet the:

         1. (i) Responsibilities of, and the resources, equipment, and performance standards for, the level of designation sought, and
         2. (ii) Overall needs of the trauma system in that region;
      3. (c) Familiarize themselves with the hospital's application and the designation standards;
      4. (d) Inspect the hospital's physical plant;
      5. (e) Interview trauma team members and management personnel;
      6. (f) Examine the hospital's trauma-related documents, including patient care records;
      7. (g) Review other materials considered appropriate by MIEMSS;
      8. (h) Provide an exit interview of preliminary findings to the applicant upon completion of the on-site review; and
      9. (i) Provide a brief written summary of preliminary findings upon completion of the on-site review.

   9. (9) Confidentiality of On-Site Review Records.

      1. (a) MIEMSS shall require and maintain confidentiality of an on-site review record.
      2. (b) An on-site review record is confidential and exempt from public disclosure under General Provisions Article, Title 4, Subtitle 3, Annotated Code of Maryland.
      3. (c) Except as provided in Health Occupations Article, Title 1, Subtitle 4, Annotated Code of Maryland, an on-site review record is not discoverable or admissible in evidence.
      4. (d) A member of the on-site review team may not divulge, and may not be compelled to divulge, any information obtained or included in on-site review records submitted to MIEMSS relating to the on-site review, including in any civil action resulting from MIEMSS' designation process.
3. C. Notwithstanding §§A and B of this regulation, instead of conducting an on-site review, MIEMSS may take into consideration or coordinate with verification surveys by the American College of Surgeons or other specialty medical organizations.

Authority: Education Article, §13-509, Annotated Code of Maryland

Effective date: March 24, 1997 (24:6 Md. R. 488)

Regulations .01—.10 amended effective July 1, 2002 (29:12 Md. R. 932)

Regulation .01 amended as an emergency provision effective June 1, 2006 (33:15 Md. R. 1276); amended permanently effective October 23. 2006 (33:21 Md. R. 1678)

Regulation .02D amended as an emergency provision effective June 1, 2006 (33:15 Md. R. 1276); amended permanently effective October 23. 2006 (33:21 Md. R. 1678)

Regulation .03D amended effective October 3, 2011 (38:20 Md. R. 1205)

Regulation .03I amended effective December 19, 2005 (32:25 Md. R. 1947); October 12, 2015 (42:20 Md. R. 1265)

Regulation .04A amended effective October 3, 2011 (38:20 Md. R. 1205)

Regulation .05B amended effective December 19, 2005 (32:25 Md. R. 1947); October 12, 2015 (42:20 Md. R. 1265)

Regulation .07C, G amended effective October 3, 2011 (38:20 Md. R. 1205)

Regulation .10 amended effective October 3, 2011 (38:20 Md. R. 1205); July 1, 2020 (47:5 Md. R. 313)